Before Being Born : Studies on Preconception Health and Unplanned Pregnancies in Low- and High-Income Settings

Abstract: Nearly half of all pregnancies globally are unplanned. They represent a failure to meet individuals’ reproductive health needs and are associated with adverse maternal and child outcomes. Preconception and contraception care can help improving outcomes of pregnancies that are desired, and preventing those that are undesired. The aim of this thesis was to investigate factors that affect individuals and their children before they are born: parental preconception health and pregnancy planning. These phenomena were studied in Sweden and in Eswatini. Furthermore, a counseling tool to improve preconception care called the Reproductive Life Plan (RLP) was evaluated in Eswatini.In Sweden, baseline data from a cohort on pregnant women (n=3,389) of different origin were used. Many Nordic-born women drank alcohol (80% n=2,400) and smoked (20% n=607) preconception. Women born outside Europe were less likely to have these habits but more likely to have an unplanned pregnancy compared with Nordic-born women (AOR 1.37; 95% CI 1.01, 1.88).In Eswatini, data from client records were used (n=1,436). Seven out of ten pregnancies were unplanned (789/1,124). Adolescents had more than two-fold increased odds of unplanned pregnancy compared with women aged 20 or older (AOR 2.39; 95% CI 1.53, 3.75). Women with unplanned pregnancies were less likely to attend antenatal care (AOR 0.68; 95% CI 0.49, 0.95). We collected qualitative data on unplanned pregnancy using focus groups discussions (n=3) with health workers called mentor mothers (n=29). Unplanned pregnancies were thoroughly perceived as negative events with major social and health implications. Driven by poor socioeconomic conditions, young women often engaged in sexual relationships characterized by violence and gender inequality, resulting in unplanned pregnancies. These pregnancies often resulted in neglected children growing up to become vulnerable adolescents at risk of becoming pregnant unintendedly, thus generating a perpetuating cycle of unplanned childbearing.The RLP was used by the mentor mothers in client counseling (n=29). Focus groups discussions (n=7) and a questionnaire were used to collect data. The mentor mothers were key persons in implementing the RLP. Using this tool, they observed progress in pregnancy planning among their clients and thought it improved quality of contraceptive care. The clients' ability to form and achieve their reproductive goals was hindered by contextual factors such as intimate partner violence and limited reproductive health and rights.